Sriwijaya B734 at Pontianak on Oct 19th 2012, overran runway on landing

Last Update: December 9, 2014 / 21:33:00 GMT/Zulu time

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Incident Facts

Date of incident
Oct 19, 2012

Classification
Incident

Airline
Sriwijaya

Aircraft Registration
PK-CKN

Aircraft Type
Boeing 737-400

ICAO Type Designator
B734

Indonesia's NTSC released their final report concluding the probable cause of the serious incident was:

The absence of approach briefing particularly on reviewing of landing distance might have decreased the pilot’s awareness toward better flight justification. This condition affected to the pilot justification which resulting the approach speed was 13 kts above Vref when the aircraft at 50 ft. And this particular condition was classified as un-stabilized approach and requires the pilot to go around.

The NTSC did not report whether the captain (49, ATPL, 16,900 total hours, no hours on type mentioned ("to be announced")) or the first officer (31, CPL, 370 hours total, hours on type "to be announced") was pilot flying.

The estimated landing weight was 120,000 lbs close to the maximum landing weight of the aircraft. The crew received weather information indicating winds from 270 degrees at 5 knots, visibility 6000 meters, temperature 26 degrees C, dew point 25 degrees C, clouds CB at 1700 feet, QNH 1007, rain and thunderstorm. Considering the weather conditions the crew decided to use autobrakes setting 3 rather than planned 2. The NTSC stated: "The pilots did not mention that they looked at the Boeing Flight Crew Operating Manual (FCOM) as reference."

The aircraft was vectored onto an ILS approach to runway 15, on final approach the aircraft encountered heavy rain. The crew acquired visual contact with the runway while descending through 800 feet and received landing clearance.

The crew reported they had noticed the navigation display showed calm winds on final approach. On short final the wind changed however, the crew noticed the aircraft was shaking. When the aircraft descended through 50 feet AGL the flight data recorder recorded a tail wind component of 10 knots, the calibrated airspeed was 150 knots (Vref 137 KIAS) and the speed over ground was 163 knots. The NTSC reported: "The Supadio Tower controller took picture of the aircraft from the tower with the mobile phone camera."

The NTSC reported that following touch down (not reported where the aircraft touched down) the aircraft bounced for 2 seconds travelling another 144 meters before settling on the runway.

The NTSC reported that the observed the runway condition the following day, when another heavy rain came down, and found that there was standing water, about 15 cm in depth (!), on the runway in the area of taxiway C which is the taxiway to the Air Force Apron.

After the aircraft settled on the runway the crew deployed thrust reversers and applied reverse thrust (N2 at 96%) but did not feel any deceleration. The flight data recorder showed a brakes pressure of around 3000 psi and a deceleration of 0.3G initially, which gradually reduced to about 0.12G during the roll out. Seeing the end of runway coming closer the crew applied manual braking (brakes pressure at maximum 3000 psi), the aircraft went past the runway end and came to a stop with the nose gear on soft ground past the end of the runway end safety area, the main gear wheels remained on the paved surface about 2 meters short of the end of the paved surface.

After the aircraft came to a stand still cabin crew checked the outside of the aircraft, saw no fire but heavy rain and reduced visibility and instructed passengers to remain in their seats. The purser was called to the cockpit, the captain briefed the purser that the aircraft had overrun the runway and issued instruction to keep the passengers in their seats. The crew radioed tower informing about the overrun, tower pressed the crash button initiating an according response by airport emergency services, who subsequently assisted the passengers in disembarking the aircraft via stairs.

There were no injuries.

The NTSC reported the aircraft received minor damage listing:

- the nose gear folded backwards
- the nose wheel doors detached
- the inboard main tyres (number 2 and 3) showed reverted rubber damage

The NTSC analysed that using the current conditions at the landing, 150 KIAS, autobrakes 3, tailwind 10 knots, wet runway with assumed medium braking action and 119,501 lbs landing weight the aircraft performance tables computed a landing distance required of 7,083 feet, due to the bounce adding 144 meters/432 feet the landing distance required increased to 7,515 feet with only 7,382 feet landing distance available.

The NTSC analysed: "Based on the interview, the investigation did not find a statement explained that the pilot reviewed part of the approach crew briefing concerning the required landing distance compared to landing distance available. Whilst part of the approach briefing in the FCTM stated that the pilot should review such landing distance."

The NTSC analysed: "The observation found that on the tire number two and number three which were the inner main wheels were found reverted rubber marks, and there was white tire marks on the runway. The reverted rubber and white tire marks are the indication of hydroplaning. The FDR data recorded that the longitudinal acceleration (negative value means deceleration) approximately -0.3 G on the initial landing roll and gradually reduced to approximately -0.12 G. This means there was reduction of the deceleration, even though the pilot applied maximum brake. The descriptions above indicated that the aircraft experienced in a hydroplaning during the landing roll."

The NTSC concluded analysis: "The standing water on the runway would potentially lead to hydroplaning occurrence to an aircraft on landing or rejected take off."

Two safety recommendations were issued to the operator, one safety recommendation to ensure standing water levels do not exceed permitted levels in rain was issued to the airport, two safety recommendations were issued to Indonesia's Directorate of Civil Aviation as result of the investigation.
Incident Facts

Date of incident
Oct 19, 2012

Classification
Incident

Airline
Sriwijaya

Aircraft Registration
PK-CKN

Aircraft Type
Boeing 737-400

ICAO Type Designator
B734

This article is published under license from Avherald.com. © of text by Avherald.com.
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